American Society of Hematology

Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT.

In patients with suspected HIT, use the “4T’s” score to calculate the pre-test probability of HIT. This scoring system uses the timing and degree of thrombocytopenia, the presence or absence of thrombosis, and the existence of other causes of thrombocytopenia to assess the pre-test probability of HIT. HIT can be excluded by a low pre-test probability score (4T’s score of 0-3) without the need for laboratory investigation. Do not discontinue heparin or start a non-heparin anticoagulant in these low-risk patients because presumptive treatment often involves an increased risk of bleeding, and because alternative anticoagulants are costly.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

1-5: The American Society of Hematology (ASH) Choosing Wisely®Task Force utilized a modified Delphi technique to collect suggestions from committee members and recipients of its clinically focused newsletter, the ASH Practice Update. Respondents were asked to consider the core values of harm, cost, strength of evidence, frequency and control. Fifty-nine of 167 ASH committee members (35%) and 2 recipients of the ASH Practice Update submitted 81 unique suggestions. The Task Force used a nominal group technique (NGT) to identify the top 20 items, which were scored by ASH committee and practice community members, with a 46 percent participation rate. ASH’s Task Force reviewed all scores to develop a 10-item list. A professional methodologist conducted a systematic literature review on each of the 10 items; the Task Force chair served as the second reviewer. Evidence reviews and source material for the 10 items were shared with ASH’s Task Force, which ranked the items according to the core values. The Task Force then identified the top 5 items plus 1 alternate. ASH member content experts provided external validation for the veracity and clarity of the items.

6–10: Suggestions for the second ASH Choosing Wisely list were solicited from members of the ASH Committee on Practice, the ASH Committee on Quality, the ASH Choosing Wisely Task Force, ASH Consult-a-Colleague volunteers and members of the ASH Practice Partnership. Six principles were used to prioritize items: avoiding harm to patients, producing evidence-based recommendations, considering both the cost and frequency of tests and treatments, making recommendations in the clinical purview of the hematologist, and considering the potential impact of recommendations. Harm avoidance was established as the campaign’s preeminent guiding principle. Guided by the 6 principles, the ASH Choosing Wisely Task Force scored all suggestions. Modified group technique was used to select 10 semi-finalist items. Systematic reviews of the literature were then completed for each of the 10 semi-finalist items. Guided by the 6 core principles outlined above, and by the systematic reviews of the evidence, the ASH Choosing Wisely Task Force selected 5 recommendations for inclusion in ASH’s second Choosing Wisely Campaign.